gender selection case study

Ethics of Designer Babies

A designer baby is a baby genetically engineered in vitro for specially selected traits, which can vary from lowered disease-risk to gender selection. Before the advent of genetic engineering and in vitro fertilization (IVF), designer babies were primarily a science fiction concept. However, the rapid advancement of technology before and after the turn of the twenty-first century makes designer babies an increasingly real possibility. As a result, designer babies have become an important topic in bioethical debates, and in 2004 the term “designer baby” even became an official entry in the Oxford English Dictionary . Designer babies represent an area within embryology that has not yet become a practical reality, but nonetheless draws out ethical concerns about whether or not it will become necessary to implement limitations regarding designer babies in the future.

The prospect of engineering a child with specific traits is not far-fetched. IVF has become an increasingly common procedure to help couples with infertility problems conceive children, and the practice of IVF confers the ability to pre-select embryos before implantation. For example, preimplantation genetic diagnosis (PGD) allows viable embryos to be screened for various genetic traits, such as sex-linked diseases, before implanting them in the mother. Through PGD, physicians can select embryos that are not predisposed to certain genetic conditions. For this reason, PGD is commonly used in medicine when parents carry genes that place their children at risk for serious diseases such as cystic fibrosis or sickle cell anemia. Present technological capabilities point to PGD as the likely method for selecting traits, since scientists have not established a reliable means of in vivo embryonic gene selection.

An early and well-known case of gender selection took place in 1996 when Monique and Scott Collins saw doctors at the Genetics & IVF Institute in Fairfax, Virginia, for in vitro fertilization. The Collins’ intended to conceive a girl, as their first two children were boys and the couple wanted a daughter in the family. This was one of the first highly publicized instances of PGD in which the selection of the embryo was not performed to address a specific medical condition, but to fulfill the parents’ desire to create a more balanced family. The Collins’ decision to have a “designer baby” by choosing the sex of their child entered the public vernacular when they were featured in Time Magazine’s 1999 article "Designer Babies". Though the Collins’ case only involved choice of gender, it raised the issues of selection for other traits such as eye color, hair color, athleticism, or height that are not generally related to the health of the child.

Prior to the Collins’ decision to choose the sex of their child, The Council on Ethical and Judicial Affairs released a statement in 1994 in support of using genetic selection as a means to prevent, cure or specific diseases, but that selection based on benign characteristics was not ethical. Some ethical concerns held by opponents of designer babies are related to the social implications of creating children with preferred traits. The social argument against designer babies is that if this technology becomes a realistic and accessible medical practice, then it would create a division between those that can afford the service and those that cannot. Therefore, the wealthy would be able to afford the selection of desirable traits in their offspring, while those of lower socioeconomic standing would not be able to access the same options. As a result, economic divisions may grow into genetic divisions, with social distinctions delineating enhanced individuals from unenhanced individuals. For example, the science-fiction film Gattaca explores this issue by depicting a world in which only genetically-modified individuals can engage in the upper echelon of society.

Other bioethicists have argued that parents have a right to prenatal autonomy, which grants them the right to decide the fate of their children. George Annas, chair of the Department of Health Law, Bioethics, and Human Rights at Harvard University has offered support for the idea of PGD, and the designer babies that result, as a consumer product that should be open to the forces of market regulation. Additionally, other arguments in favor of designer baby technologies suggest that parents already possess a high degree of control over the outcome of their children’s lives in the form of environmental choices, and that this should absolve some of the ethical concerns facing genetic selection. For example, parents keen on establishing musical appreciation in their children may sign them up for music classes or take them to concerts on a regular basis. These choices affect the way a child matures, much like the decision to select certain genes predisposes a child to develop in ways that the parents have predetermined are desirable.

The increased ability to control and manipulate embryos presents many possibilities for improving the health of children through prenatal diagnosis, but these possibilities are coupled with potential social repercussions that could have negative consequences in the future. Ultimately, designer babies represent great potential in the field of medicine and scientific research, but there remain many ethical questions that need to be addressed.

• Agar, Nicholas. American Institute of Biological Sciences. “Designer Babies: Ethical Considerations,” http://www.actionbioscience.org/biotech/agar.html (Accessed October 16, 2010).
• Annas, George. “Noninvasive Prenatal Diagnostic Technology: Medical, Market, or Regulatory Model?” Annals of the New York Academy of Sciences 721 (1994): 262–8.
• Council on Ethical and Judicial Affairs, American Medical Association. “Ethical Issues Related to Prenatal Genetic Testing,” Archives of Family Medicine 3 (1994): 633–42.
• Kitcher, Philip. “Creating Perfect People.” In Companion to Genetics , eds. Justine Burley and John Harris, 229–42. Boston: Blackwell Publishing, 2004.
• Lemonick, Michael. “Designer Babies.” 153, Time Magazine, January 11, 1999.
• Morales, Tatiana. CBS News. “Choosing Your Baby’s Gender.” http://www.cbsnews.com/stories/2002/11/06/earlyshow/contributors/emilysenay/main528404.shtml (Accessed October 17, 2010).
• Verlinsky, Yuri. “Designing Babies: What the Future Holds,” Reproductive BioMedicine Online 10 (2005): 24–6.

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“I Have Nowhere to Go”: A Multiple-Case Study of Transgender and Gender Diverse Youth, Their Families, and Healthcare Experiences

Megan s. paceley.

1 School of Social Welfare, University of Kansas, 1545 Lilac Lane, Lawrence, KS 66045, USA; ude.uk@adnanaj (J.A.); moc.liamg@8150sivadrt (T.D.M.)

Jennifer Ananda

Margaret m. c. thomas.

2 Luskin School of Public Affairs, University of California Los Angeles, 3250 Public Affairs Building, Los Angeles, CA 90095, USA; ude.alcu.niksul@samoht

Isaac Sanders

3 A Way Home Washington, 1200 12th Ave. S. Suite 710, Seattle, WA 98144, USA; gro.awemohyawa@srednasi

Delaney Hiegert

4 School of Law, University of Kansas, 1535 W 15th Street, Lawrence, KS 66045, USA; moc.liamg@tregeihcd

Taylor Davis Monley

Associated data.

Data are not made available to protect the privacy of participants.

Transgender and gender diverse (TGD) youth experience health disparities due to stigma and victimization. Gender-affirming healthcare mitigates these challenges; yet, we have limited understanding of TGD youth’s healthcare experiences in the U.S. Midwest and South. Using a multiple case study design, we aimed to develop an in-depth and cross-contextual understanding of TGD youth healthcare experiences in one Midwestern state. Families with a TGD child under 18 were recruited with the goal of cross-case diversity by child age, gender, race, and/or region of the state; we obtained diversity in child age and region only. Four white families with TGD boys or non-binary youth (4–16) in rural, suburban, and small towns participated in interviews and observations for one year; public data were collected from each family’s community. Thematic analysis was used within and across cases to develop both family-level understanding and identify themes across families. Findings include a summary of each family as it relates to their child’s TGD healthcare experiences as well as the themes identified across cases: accessibility and affirming care. Although limited by a small sample with lack of gender and race diversity, this study contributes to our understanding of TGD youth healthcare in understudied regions.

1. Introduction

Transgender and gender diverse (TGD) youth experience stigma and victimization in their homes, schools, and communities [ 1 ]; these experiences are associated with increased health concerns, including depression, suicidality, substance abuse, eating disorders, and stress [ 2 , 3 , 4 , 5 ]. These health concerns can be mitigated or alleviated by supportive individuals and communities. When TGD youth report having at least one supportive adult in their lives, their risk of suicidality decreases by 40% [ 6 ]. Additionally, TGD youth report decreased depression and suicidality when people in their lives use their chosen names [ 7 ]. Communities can also reduce risk for TGD youth via TGD-inclusive non-discrimination policies, presence and visibility of other TGD people, and access to affirming resources [ 8 ].

An important resource for TGD youth is access to physical and mental healthcare that is affirming of their gender identities and expressions [ 8 ]. At the broadest level, having affirming healthcare means access to providers who use a patient’s chosen name and pronouns and affirms their gender. More specifically, gender-affirming healthcare for youth includes access to puberty blockers (to safely delay puberty associated with sex assigned at birth), use of hormones consistent with their gender, and medications to promote physical development [ 9 ]. Gender-affirming healthcare is recognized by major pediatric medical organizations as evidence-based practice for TGD youth [ 10 , 11 ] and is associated with reduced health disparities [ 12 ] including risk of suicide [ 13 ].

Even with this professional recognition, gender-affirming care is facing significant social and political backlash. In early 2021, in the U.S. more than 20 bills were proposed that aim to restrict gender-affirming healthcare for TGD children and adolescents [ 9 , 14 ]. These bills include provisions making it a criminal act to provide gender-affirming care (for medical professionals and/or parents), opening medical professionals up to civil liabilities for providing gender-affirming care to youth, and/or restricting insurance coverage for gender-affirming care for people under 18 [ 9 ]. If passed, these bans could restrict access to gender-affirming care for as many as 45,000 TGD youth in the U.S. [ 9 ], primarily in Midwestern and Southern states.

Access to affirming physical and mental healthcare is a critical component of reducing health disparities for TGD youth, yet we lack research on the healthcare experiences of TGD youth in the U.S. Midwest and South, precisely those areas where TGD youth face heightened risks for health disparities. Simultaneously, legislation in these regions is targeting TGD youth via restrictive and discriminatory policies and rhetoric. To redress this critical gap in the literature, this study centers the lived experiences of TGD youth and their families in one Midwestern state with the goal of understanding their healthcare experiences broadly and related to gender-affirming care specifically.

1.1. TGD Youth in the Midwest

The Midwest is characterized as having low tolerance for sexual minorities [ 15 ]. TGD youth in the Midwest and South report higher rates of anti-TGD victimization compared with TGD youth in other regions of the country [ 16 , 17 ]. Few studies have centered an understanding of the Midwest context on the experiences and well-being of TGD and sexual minority youth. One study explored the community context of TGD youth living in rural communities in a Midwestern state [ 18 ]. They found that community climate (e.g., the level of support for TGD people in a community) was a better predictor of supportive resources than was community size. This finding suggests that it is critical to identify strategies to increase support for TGD people within their communities. Another study examined the community factors relevant to how TGD youth perceive support in rural and small towns in the Midwest [ 8 ]. Youth described a lack of TGD-affirming resources, including healthcare options that affirmed and supported their identities.

1.2. TGD Youth Healthcare

Access to supportive and competent healthcare can reduce health concerns and promote well-being for TGD youth [ 19 ], yet TGD youth face barriers to accessing both general and gender-affirming healthcare. Specifically, barriers to healthcare for TGD youth include fears of mistreatment based on gender [ 20 , 21 ] and providers using youth’s incorrect names/pronouns [ 20 , 22 ]. Additionally, TGD youth face barriers to gender-affirming care such as lack of competent providers [ 21 , 22 , 23 ], lack of access to puberty blockers or hormones [ 20 , 22 ], and insurance and financial issues [ 21 , 22 ]. Alternatively, affirmation of TGD youth’s gender is associated with reduced barriers to affirming care for TGD youth of color [ 24 , 25 ].

Importantly, access to supportive and affirming healthcare extends beyond provider competency and accessibility. For TGD youth under the age of 18, parental consent and support is often a prerequisite to care [ 26 ]. Very few studies have examined the healthcare experiences of TGD youth from the perspective of both youth and parents. A qualitative study of TGD youth and parents in Newfoundland found that while both youth and parents identified the barriers described above, parents also discussed concerns about their child’s mental health, wait times for access to care, and a lack of information on providers and gender-affirming care [ 23 ]. Additionally, youth specifically worried about parental acceptance, safety, and feelings of dysphoria.

These studies provide an important understanding of the healthcare experiences of TGD youth, and yet there remain key gaps in the literature. Given the important role of parents in the provision of healthcare for TGD youth, we need more studies including both youth and parent perspectives. Additionally, healthcare access and affirmation may be different in regions and communities with less supportive attitudes and resources, such as the U.S. Midwest and South. Finally, existing studies have primarily used cross-sectional surveys or interviews, providing important details at a point in time. We lack studies exploring the lived experiences of TGD youth and their families over time. Therefore, the purpose of this study was to center the lived experiences of TGD youth and their families in one Midwestern state over the course of a year with the goal of learning about their experiences with healthcare.

2. Materials and Methods

We used a multiple case study design to explore the healthcare experiences of TGD youth and their families in one Midwestern state. Multiple case study designs allow for in-depth exploration of a phenomenon across varying contexts or situations [ 27 ]. Four families in one Midwestern state participated in the study over the course of twelve months (July 2019–June 2020). All procedures were approved by the University of Kansas ethics review board.

2.1. Positionality

As scholars engaged in research-advocacy with TGD youth, it is essential that we identify our positionalities within the study. Author one (she/they) is a queer, white, genderqueer woman with professional, educational, and class privilege. They have over a decade of practice experience working with TGD youth. They led the study, engaged in all data collection and analysis, and were the primary contact for all families. Author two (she/her) is a white, queer, cisgender woman with professional, educational, and class privilege. She engaged in data analysis and dissemination. Author three (she/her) is a white, lesbian, cisgender woman, with class, educational, and professional privilege. She joined the study during the dissemination phase as a policy expert. Author four (they/them) is a Black, two spirit, queer person with professional and educational privilege. They joined the study during the dissemination phase as a TGD practice expert. Author five (they/them) is a white, queer, transmasculine nonbinary person with professional, educational, and class privilege. They engaged in data analysis and dissemination. Author six (she/her) is a white, queer, cisgender woman. She was involved in the study from the start and engaged in data collection, analysis, and dissemination.

2.2. Recruitment and Sampling

A multiple case study design requires the selection of cases (i.e., families) who have a similar connection to a phenomenon (i.e., TGD healthcare) but with different contexts or situations [ 27 ]. We aimed to recruit and retain four families who lived in the sampled state and had at least one child under the age of 18 who identified as transgender, non-binary, or gender diverse. We also aimed to include varying contexts to explore diversity across cases; specifically, we hoped to include children of varying age, race/ethnicity, and gender identities or expressions, as well as families in multiple regions of the state.

Families were recruited via advertisements on social media, emails from LGBTQ+ organizations, and professional connections throughout the state. Interested parents or children were asked to email or call the first author to establish eligibility and consent. For each family, the parent was the initial contact. A total of five families consented to participate. One family withdrew after data collection began, and their data are not included. Although we attempted to recruit a diverse sample in terms of race/ethnicity and gender, the final set of families included only age and regional diversity. Table 1 describes the characteristics of each family. Notably, all families were white and three youth participants were trans boys.

Family Case Characteristics.

Note. Pseudonyms are used to protect family anonymity.

2.3. Data Collection

Data collection included three or four in-depth interviews with parent and child participants, observations of each family, public document review, and member checking/data review by each family. Data collection occurred between July 2019 and June 2020. Due to the onset of COVID-19 in early 2020, all data collection after March 2020 was conducted online.

2.3.1. Interviews

Multiple interviews were conducted with each family to understand their individual contexts and experiences, attending to changes over time. After receiving initial agreement to participate in the study by parents and children, we set up a time to meet the families in person. The first and last author traveled to meet the families in their homes. At the first meeting, we brought food, snacks, and/or things to play with (for the family with younger children) to establish rapport and get to know the family before starting data collection. Consent documents were shared and parents provided signed consent for themselves and their child. Children received an assent form and provided verbal agreement to participate. Families participated in three to four interviews over the course of twelve months, spaced about three to four months apart. Parents and children received a USD 20 gift card for each data collection visit for a total of up to USD 160 per family.

An interview guide was used to facilitate each interview. The first interview guide was developed to establish an understanding of the child, family, school, community, and healthcare contexts. Initial interviews with parents and children were conducted separately to provide privacy and confidentiality for all families except one (due to age of the child). The parent interview guide included questions related to their interest in the study, family background, their TGD child, their child’s physical and mental healthcare experiences, and needs of the family. The child interview guide was adapted based on the age of the child and included questions related to their family, gender, healthcare experiences, and any need for support they had. Subsequent interview guides were developed for each family based on their individual contexts and after preliminary analyses of their previous interview(s). Subsequent interviews focused on changes since previous meetings, past and upcoming healthcare appointments, shifts related to gender identity or expression, and ongoing or new needs for support. Two families elected to conduct these subsequent interviews as a family, rather than individually (both were the two families with younger children). All interviews were audio recorded and transcribed by a professional transcription service.

2.3.2. Observations

Participant observations were used to document and explore family dynamics and contexts. At each family meeting, we engaged with the parent(s) and child together before and after interviews. Following each meeting, we individually documented our observations of the family, family dynamics, and possible topics for further exploration. Observations included memos from the interviews. Observation memos were written within 48 h of each meeting, and we also discussed our reactions and thoughts as a group.

2.3.3. Public Document Review

Public documents in each family’s community were collected to understand the healthcare and community context for each family. Public data included the presence or absence of TGD-affirming healthcare services, non-discrimination policies inclusive of gender identity, and any other relevant public documents, such as lists of TGD-affirming healthcare providers.

2.3.4. Member Checking/Data Review

At the end of the data collection period (Summer, 2020), each family was provided with a two-to-three-page summary description of their family contexts and TGD healthcare experiences. They were asked to read and review it for accuracy and anonymity, allowing them the opportunity to change details or obscure facts that might make them easy to identify. No families asked to change any information. They were asked to answer a few questions via email in their response, including whether there had been any changes or updates since their last interview, feedback they hoped healthcare providers would take from this study, and ideas for training healthcare professionals. All families responded to the questions, and these responses were incorporated into the analyses.

2.4. Data Analysis

Data for this study included interview transcripts, observation notes, public documents, and member checking reviews. Given the multiple case study design, it was essential to analyze these documents within cases (e.g., each family) and across cases (e.g., the entire data set). This allowed for an in-depth understanding of each family’s contexts and experiences and for the comparison of data across cases. This is an essential step in a multiple case study with the goal of understanding each individual case and identifying similarities and differences across cases [ 27 ].

The first and last authors began analyzing data within families at the start of data collection to develop a thematic understanding of each family prior to the subsequent interview/meeting. Interview transcripts and observation notes were read by each author who each took notes about emerging ideas and codes to attend to in subsequent rounds of analysis. These notes were used to create interview guides for subsequent meetings with families, including follow-up questions from within-case analysis (e.g., “Tell me more about what happened when the doctor….”) and across cases (e.g., “Some families are reporting [a specific experience]. Has that been true for you).

When data collection ended, the first and final two authors engaged in the thematic analysis procedures outlined by Braun and Clark [ 28 ]. Each author read all data materials to establish familiarity within each family and then across cases. Next, codes were generated within data related to healthcare experiences, needs, and concerns. We developed themes and then reviewed them to ensure accuracy and that no other codes or themes were missing. One author then wrote family summaries using these themes and sent them to the families for review. Families were able to make corrections or omissions and answered a few final questions; these answers were used in the final round of analyses. Themes were then compared across cases by coding excerpts for similarities and differences and compiling them into a set of themes that described the findings across all four cases.

With the goal of providing a rich description of each case, as well as sharing insights across cases, the findings from this study are presented in two parts. First, we provide a brief but in-depth description of each family and their healthcare experiences. Second, we share the findings from the across-case analyses demonstrating two broad themes of TGD healthcare experiences: accessibility and affirming care.

3.1. Family Descriptions

3.1.1. family 1.

Travis was 16 years old at the start of the study, the middle child of three siblings, living with his mom and dad in a rural town. Although adjacent to an urban county, the community had a small town feel with neighbors waving at cars as they drove by and a small, walkable downtown in which we picked up lunch for the family on our first visit. There were no TGD-affirming providers within the county, and the county had no legal protections for TGD people. An urban city is about an hour away, providing access to resources, but only if one were able to make the drive. Throughout the course of the study, Travis’ family had access to medical care and private insurance. Travis and his mom, Carrie, were open, loving toward each other, and friendly. Travis shared his love of music, art, and writing.

Travis explored his gender on his own for years prior to telling his parents he is trans at the age of 13. They were supportive of him, using his correct name and pronouns, finding TGD-affirming providers, and advocating for him. Travis indicated his school was mostly supportive, but he described instances where, in an attempt to be supportive, the school would do things like ask what group he preferred when events were separated by gender, which he felt like they should know, given he is a boy. Although he was generally reserved, he had gotten involved in advocacy efforts with his school’s gender and sexuality alliance (GSA). Travis attended an LGBTQ+ organization in the neighboring city, providing him with social support and resources.

Travis sought both TGD-related medical and mental healthcare. He described his therapist as helpful and affirming. He first saw his family doctor for gender-related care; however, the doctor was uncomfortable with this and provided no referrals. Carrie explored other options and eventually found a transgender-friendly clinic, referred by friends from the LGBTQ+ center. Travis receives hormones and ongoing care from the clinic, which has been affirming and competent; physicians and nurses use proper language, understand how to work with TGD youth, and ensure TGD people feel comfortable. However, the clinic is an hour away, and there have been logistical challenges with scheduling and physician turnover. Carrie described several examples of times in which their insurance initially would not cover visits to the clinic due to coding issues or confusion about Travis’ gender. After phone calls to the insurance, these issues were resolved; however, it required time and emotional labor on Carrie’s behalf. She described their healthcare hurdles to be finding and accessing TGD-affirming healthcare and navigating insurance challenges, such as improperly coding TGD-related healthcare as not covered.

3.1.2. Family 2

Aiden was 15 years old, the youngest of two, living with his mom and dad in a suburban community. The town had a long-standing non-discrimination ordinance that included gender identity, as well as numerous therapists skilled at working with TGD youth. There were a few medical providers affirming of TGD people; however, there were no TGD-specific providers or centers. The city is about an hour from an urban community that had numerous TGD-affirming providers, including a gender clinic for children, if families could make the drive. Aiden and his family had lived in this community for a couple of years, having moved from another state due to transphobia. They had access to private insurance and means to travel and pay for medical care. Aiden shared enjoying physical activity and playing video games. Throughout the study, Aiden and his mom, Vanessa, as well as other family members who stopped in to say hi, were friendly and welcoming. Aiden and Vanessa appeared to have a strong, trusting relationship.

Aiden knew at five that his gender was not what people expected of him, but he did not have the words for it at such a young age. Vanessa described wondering if her child might be transgender and meeting with a mental health professional to ensure they were providing Aiden with the right types of support. At 10, he met with a gender-affirming therapist and then came out as transgender, changing his name and pronouns and starting hormone blockers to delay puberty. His family has been incredibly supportive, advocating for him when his school denied him use of facilities consistent with his gender (e.g., boys’ bathrooms), and eventually moving to provide him with a more accepting community and resources.

Aiden’s experiences with healthcare have been mixed. He described his previous doctor as “scared” of him, as he refused to prescribe hormones even after a therapist said Aiden was ready. He switched doctors and found a general practitioner who was TGD-affirming. He also visited the gender clinic in the neighboring urban city every four weeks. He sees a local therapist who is skilled at working with TGD youth. Aiden and Vanessa described generally positive experiences with healthcare but indicated that barriers existed with physician training and education on how to work with TGD people.

3.1.3. Family 3

Blake was 11 years old, the middle child of three kids living with their mom, Faith; Blake’s dad lived in another state. Although they lived within an urban city, their home was situated on the outskirts of town, just off a major interstate, giving it a more rural feel. Despite that, the city is one of the largest in the state and has several LGBTQ+ organizations and TGD-affirming healthcare providers. At the time of this study, the city did not have any policies protecting TGD people from discrimination. Blake shared his joy of cats, art, and rock collecting, as well as experimenting with make-up and fancy clothes. During our meetings, the family often had spirited conversations, sometimes openly disagreeing with each other’s take on situations, but also demonstrating closeness and care.

Blake had been exploring his gender and sexuality for a few years. He reported feeling both like a boy and non-binary, as well as bisexual, but expressed no desire to change his name or pronouns from those assigned at birth. He described liking make-up, high heels, and dresses. At times, Faith questioned this and Blake would respond adamantly that liking these things did not make him a girl. He was allowed to start wearing make-up in public, including at school, when he started the 6th grade, the same as his older sister had been.

Blake was in both family and individual therapy. Faith shared that Blake started individual therapy at a local clinic for multiple reasons, of which gender and sexuality were a part, but that his therapists would only discuss gender and sexuality if he brought it up. Faith expressed concern that this was about their discomfort with TGD issues. Blake shrugged, indicating he had no concerns about his gender or sexuality. Blake had not told his primary doctor about his gender or sexuality, but Faith reported feeling as if they would be competent. Blake indicated no desire for any medical transition or gender-related care at this time. Faith shared that the biggest hurdle she witnessed regarding TGD-affirming care was in education for mental health providers. As a clinician herself, she shared that psychologists and social workers needed better and more ongoing continuing education on working with LGBTQ+ youth.

3.1.4. Family 4

Ethan was four years old, living with his twin sister, mom, and dad in a small town. Situated in a more conservative and less densely populated area of the state, the town was unique in having a county-wide non-discrimination ordinance that included gender identity. There are no gender clinics or specific TGD-affirming providers in the community; however, there is a human rights organization providing training and resources to physicians providing care for all genders. Additionally, a more urban area, about an hour’s drive away, hosts additional resources for access to care. Ethan, his mom, Natalie, and their family were well-established in the community and the family had insurance through Natalie’s job. Ethan loved coloring, playing with toys, and laughing with his sister. During our visits, the family was loving toward each other and reported intentional efforts at building family cohesion and community.

Ethan began talking about his gender as a boy at 2 ½ years old. He regularly said he was a boy, would wear boy clothes, and questioned his own body. When we first met with Ethan and his family, he was using his name provided at birth and she/her pronouns. He appeared shy and reserved, though warmed up quickly and wanted to play with us. When we visited the second time, his demeanor had changed completely. He was using the name Ethan and he/him pronouns, had cut his hair, and was expressing his gender as a boy full-time. Natalie informed his preschool teacher, sharing that she “didn’t give them a choice” about whether to accept him or not. She said his Kindergarten the next year had a gender-inclusive policy, and she was not worried.

Natalie shared that Ethan’s general practitioner was open and supportive of Ethan and the family, noting no potential concerns. She shared that she sought out the expertise of a child therapist to identify how best to support Ethan, but the therapist shared harmful rhetoric surrounding a gender binary as opposed to being helpful. Although Ethan was too young for any TGD-specific medical care, Natalie shared concerns about being able to access that type of care in their town as Ethan got older. She indicated a barrier to effective care for Ethan is in the lack of education and training of medical and mental health providers.

These family descriptions illustrate how families navigated TGD youth healthcare, broadly and related to gender. Importantly, all the youth in the study had supportive parents willing to advocate for them to access affirming care. Most had the financial resources, insurance, and/or ability to travel to access care. This is clearly not the situation for many TGD youth; however, the themes that emerged across the families revealed important implications for access to TGD healthcare, likely relevant for TGD young people across contexts.

3.2. TGD Healthcare

Thematic analysis across data sources and families resulted in two themes related to healthcare: accessibility and affirming care.

3.2.1. Accessibility

Youth and their parents described accessible healthcare as access to TGD healthcare information, having TGD-competent providers, and safe physical resources that were obtainable given their financial and geographical location. Each family shared stories about accessibility, recognizing their own privilege of access due to supportive parents with stable incomes and access to transportation. Even so, each family shared accessibility challenges including a lack of TGD healthcare information/providers, material hardship (finances, distance), and safe physical resources. Importantly, these challenges intersected to either enhance or further limit accessibility.

Participants discussed challenges in finding information related to local healthcare providers who could work with TGD youth. One parent said:

We didn’t know where to go; doing random Google searches does not get you what you need, and looking that up on our providers care site, there was nothing. I mean, I could find 50 endocrinologists, but none of that told me if they would be able to help with this situation.

While an internet search revealed resource lists of health providers in some communities in the state, many communities had no such information consolidated or readily available online. In addition to online searches, participants noted that they also sought information regarding TGD healthcare from their child’s primary doctor. They noted that, while well-intentioned, their child’s doctors often did not have referrals for healthcare services for TGD youth. Ultimately, most families in the study relied on information provided by other TGD youth or organizations that provide support for TGD youth and their families. A youth shared how they were able to access information word-of-mouth through other TGD connections: “if I didn’t go to the [LGBTQ] center, and if I didn’t meet my friend who told me about [TGD healthcare provider], I don’t know what would have happened.”

Even when families found and accessed TGD-affirming physicians, they shared concerns about high turnover rates and a general lack of physicians in their areas. This was particularly salient for rural TGD youth. One youth shared feeling as if they had to re-establish rapport regularly due to changing physicians at the clinic, speculating that turnover could be related to working in a high-stress clinic that also provides abortion services, where protesters regularly gather and individuals experience harassment when entering and exiting the clinic.

Safety, therefore, was of particular concern to the youth and parents. They described accessing gender-affirming care through “women’s clinics”, walking through protesters, and being yelled at. One youth said:

Where I go, it’s [women’s clinic]. So they do more women’s health care. They do abortions and stuff there, too, so it’s like that’s why they have that much security cause you go through a metal detector, and the door’s locked. And then he has to unlock the door for you…But then they also do trans stuff on top of that.

Another youth described the safety planning required to enter the facility where they accessed services.

There are lots of anti-abortion people. They’re all like, there’s a building right next to them, and they have a sign that’s like, ‘Planning getting an abortion? We can help you, because we’re religious.’ They have a big truck with a really graphic image on it, which is probably fake, and they have tables and flyers. Before my first appointment, they called me and was like, ‘When you get there, just drive on in like you work there. Just ignore them, and they probably won’t try to talk to you.’

Experiencing protesters, having to go through security protocols, and other similar experiences were common for youth accessing TGD healthcare in a women’s clinic setting.

Finally, families described material hardships related to accessibility such as affordability, insurance restrictions, and travel to access resources, even in homes with adequate family support and resources. Parents experienced insurance companies’ coding mistakes that led to lengthy conversations with Human Resources to ensure that hormones and other medical needs were covered for their child. They also described instances in which visits were not covered by their insurance provider, but they were unaware until after the appointment was billed and sometimes after multiple appointments. TGD youth were also aware of the costs for medical care. One participant said:

I mean, I have a friend, and he’s getting top surgery in June or July, which is awesome for him. But I’m not. And it’s very expensive. I know, I have to wait at least another two years, if that, if I have the money. So it’s just kind of bittersweet, I guess. Because I’m really excited and happy for him. Because he’s been wanting this since- For so long.

Travel was another accessibility issue. Most of the youth in this study had to travel, sometimes an hour or more, to access a physician who competently addressed their healthcare needs.

3.2.2. Affirming Care

Affirming care was described by youth and their parents as affirming practices within the healthcare setting, having knowledge and attitudes that met their needs, and affirming spaces to access healthcare. Families identified specific instances in which name and pronoun use, providing education and referrals, and gendered space impacted their perceptions of the care they received as affirming or presented challenges to accessing affirming care.

Affirming practices were identified by participants as a broad range of affirming behaviors exhibited by or desired from healthcare providers, including using correct names and pronouns, requesting consent before engaging in services, and providing education to TGD youth as they engaged in hormone therapy. These behaviors significantly impacted participants’ perceptions of their experiences.

I mean even just the normal things, asking pronouns. One thing I’ve been reading some about is consent and this isn’t just for trans (people), but obviously it could make a big difference. Even when the doctor comes to check your pulse, ‘Is it okay if I grab your arm and then I’m going to check.’ …Just that kind of consent would be in having a more trusting and comfortable relationship.

One family in the study discussed an event that had a significant impact on their experience. A parent described it, saying,

She brought us in, and she went over it all, she showed us everything. I mean, she went into detail. And then she gave us a sharps bucket, she gave us all kinds of extra needles for practicing, and for using, gave us all this stuff. It was like this, we call it his little trans starter kit, she gave us. She was so, I mean, that made such a world of difference for us. She was amazing…

Affirming behaviors from medical professionals created an environment in which TGD youth felt more comfortable accessing the care they need.

Participants also relayed concerns about healthcare professionals’ education on gender-affirming healthcare and their inability to provide safe and effective referrals. Participants regularly went first to their general practitioners for references for gender-affirming care.

We didn’t know where to start. We really like our general practitioner, so we just set up his regular physical and started by talking to her, and she said, ‘Well, I don’t feel comfortable with that. I’m not an endocrinologist, and I don’t know enough about it,’ and she said, ‘And I would not recommend the endocrinologist in town. There’s only one.’ And she said, ‘That’s just, he does not seem like the right fit.’ She tried to help us, but we ended up getting a reference from a friend at the Center, and we go to the (Clinic’s name).

Participants noted that their practitioners seemed uncomfortable and uninformed when discussing gender-affirming care and saw gender-affirming referrals through their general practitioner as a barrier to finding care. “I think it would be easier to access that stuff through your family doctor, just going, and if you would tell them, and then they would be like, ‘Oh here’s a bunch of things we can do for you, whichever works best.’” One participant acknowledged the discomfort expressed by their general practitioner when a referral was requested, “I think doctors should be more educated on the topic because my doctor doesn’t really know a lot about trans people in general. She has a general idea, but she doesn’t know anything pretty much.” Many participants were able to find a referral to a practitioner who offered affirming care through interpersonal relationships, but they expressed concerns about accessing healthcare for other medical needs.

Yeah, and I mean so far we’ve been very lucky. He’s got a great primary care physician who’s… We’re fine. But just, every time we see somebody new, I mean I made a point when choosing a primary care physician that that would be something on the list. But if he ever has to see a specialist, or if he ever has to go to the emergency room, who knows what we’re going to find?

Concerns about accessing healthcare professionals outside of gender-based care, such as the emergency room or other emergent healthcare needs, was a concern for participants.

Additionally, participants acknowledged the need for those healthcare professionals who provide gender-affirming care to remember that youth accessing their services are not medical professionals themselves and require education and information about the care they are receiving. One participant said, “I think for young trans kids, I feel like they just…I didn’t know a lot even, and I feel my doctors didn’t really tell me enough. And I never really got what was going on. I would ask my mom and she would just tell me we’re moving in the right direction.” There may be a presumption from medical providers that youth accessing their services understand gender-affirming medical care because they sought out those services.

Gendered spaces also impacted participants’ access to affirming care. Specifically, a transmasculine youth shared discomfort about accessing women’s clinics.

It kind of made me uncomfortable at first. It still kind of makes me uncomfortable. Because I was talking to my friend, and he’s cis. And I was just like, “Oh yeah, I go to (clinic’s name).” And it was like, uh, women… Not women, but it says women in the title. And it’s pink on the card, and just like, I’m not a woman, but I go there. So it makes me kind of uncomfortable.

Another youth participant noted discomfort accessing services in a “women’s” space.

I’m like, ‘Oh, I’m not a woman, but I’m going here,’ and if I’m walking, I was like, ‘I hope no one sees me walking in here.’ Or if I talked to other people, they’re like, ‘Oh, where do you go?’ I was like, ‘Oh, I go to (Clinic’s name).’ It was like, ‘What?’

Participants mentioned a desire to have a space that was broadly available for gender-based care, “It would be amazing if there were a center here. Just gender in general, gender medical-based center that you could go to for all those things.” Even if women’s clinics are able to provide gender-affirming care, the gendered nature of the center can impact the affirming care TGD youth receive in those spaces, even if healthcare professionals there provide affirming care for TGD youth within the facility.

4. Discussion

This study explored the healthcare experiences of four TGD youth and their parents in one Midwestern state. Through extensive interviews, two broad themes arose that were explored in this paper: accessibility and affirming care. Findings reveal that even in supportive families with access to financial resources and community support, TGD youth face barriers to accessing affirming healthcare. Specifically, accessibility was limited by lack of information on TGD healthcare providers, financial resources and insurance restrictions, and safety of physical locations. Affirming care included knowledgeable and affirming providers and healthcare spaces and specific practices that demonstrated competence and care to TGD youth. These findings enhance our understanding of healthcare among TGD youth in the Midwest U.S.

A key finding from this study is the fact that even in supportive families, TGD youth experienced barriers to accessing TGD-affirming healthcare, including finding resources, financial barriers, and geographic limitations. Parents regularly discussed spending hours on the internet, talking to other parents, visiting LGBTQ+ resource centers, and calling doctors and clinics to find competent and affirming care for their child. This echoes findings from recent research that TGD youth lack access to competent healthcare providers [ 21 , 22 , 23 ]. Importantly, each family in this study had adequate health insurance coverage and yet still faced financial barriers to care, including travel to access resources and insurance challenges. Prior research has identified insurance and finances as a barrier to accessing TGD-affirming care [ 21 , 22 ]. Travel to access gender-affirming healthcare has not been specifically examined in TGD healthcare literature; however, it has been identified as a barrier to TGD and sexual minority youth access to affirming community-based resources [ 29 ].

Another finding from this study illustrates the importance of affirming practices from medical and mental healthcare providers. Several of the families in this study started their gender-affirming healthcare experience with the child’s primary care physician. Many of those providers were uncomfortable providing care or making referrals. Families also worried about what kind of care they might receive if their TGD youth had to go to the emergency department. This suggests that access to gender-affirming care is not just about access to gender-specific care, but also access to medical and mental healthcare providers and systems that are affirming regardless of what type of care a person needs.

4.1. Limitations

This study has important limitations to note. As an exploratory multiple case study, the findings should not be generalized to other populations or geographic settings. The nature of the study required parental permission and involvement, which meant parents who agreed to participate were more supportive than in other families with TGD youth. Finally, despite attempts to diversify the sample by both race/ethnicity and gender identity/expression, the final sample of families were all white and had TGD children who were transmasculine or non-binary; youth/families of color and transfeminine youth were not included. We make conclusions carefully considering these limitations.

4.2. Implications

The findings from this study are relevant to the current sociopolitical context for TGD youth and, combined with other evidence, have important implications for policy and practice. Given the rise of anti-TGD legislation and rhetoric, including particular emphasis on reducing access to healthcare services for TGD youth [ 9 ], it is critical that social workers, healthcare providers, and other professionals advocate for inclusive policies that promote access to affirming care for TGD people. Resisting anti-TGD legislation is an important place to start; however, professionals and advocates should also promote gender-inclusive policies at city, state, and national levels. Advocating for non-discrimination policies that are inclusive of gender identity and expression is an essential step toward promoting healthcare access and reducing discriminatory practices. Opposing additional access and affordability barriers to healthcare for TGD youth is both an ethical imperative and grounded in sound policy reasoning. The nondiscrimination provisions of the Affordable Care Act and other federal law, such as the Title IX civil rights provisions barring discrimination based on sex, may be interpreted as protecting the rights of TGD youth to equal access to care [ 30 ].

Additionally, this study’s findings highlight the enormous challenges which insurance policy and practice can pose for families of TGD youth. The families in this study all had access to private health insurance, a status associated with fewer insurance denials of TGD-related healthcare among adults, as compared to those with public health insurance [ 31 ]. Nonetheless, families reported routine insurance challenges, indicating the importance of improving both insurance policy and practices. From a policy perspective, the challenges families faced may reflect the important state and regional differences which motivated the present study’s attention to experiences in a Midwestern state. Current data on state-level TGD exclusion and inclusion in health insurance coverage indicate that nearly all Midwestern and Southern states do not have policies requiring coverage of TGD-related healthcare by private health insurance companies [ 32 ]. Moreover, state Medicaid policy in several Midwestern and Southern states explicitly excludes TGD healthcare coverage [ 32 ]. With many states’ policies to draw on as models, the clear policy implication is to expand bans on TGD exclusion from private and public health insurance coverage.

In addition to policy change, insurance-related practices emerged as a barrier to families, suggesting the importance of extending education and training to people who work with insurance claims. This might include healthcare organizations’ billing department employees and insurance companies’ customer service staff. While these are not the clinicians who often have direct contact with TGD youth, their work in coding, checking, and resolving insurance issues requires sufficient education and training to understand the experiences and healthcare needs of TGD youth and therefore interpret and process insurance claims correctly.

At the practice level, all participants in this study noted a lack of training for medical and mental health providers related to working with TGD people. As providers become more aware of, and more TGD youth access healthcare services for other healthcare needs, such as emergency room services, the need for training for all medical personnel will continue to expand. Eisenburg et al. [ 33 ] advocated for physical and healthcare provider training on a regular basis, and creating a system for tracking who has been trained and who is willing to provide support for TGD youth. This would help not just with training healthcare professionals but with providing resources for families to identify potential doctors or clinicians for their child. Training should consist of topics such as TGD-affirming language, debunking myths about TGD people and youth, and other medically relevant resources [ 33 , 34 ]

Relatedly, a critical practice implication of this research is a greater need for access to TGD-affirming resources. Physicians, mental health providers, and other groups such as LGBTQ+ community organizations should create and sustain a TGD-specific resource guide [ 33 ]. Such a guide can support both providers and families with finding affirming and accessible healthcare resources, reducing time spent seeking resources, helping providers make referrals to affirming providers, and providing autonomy to TGD youth who might not have familial support. This type of guide could be similar to resource guides present in large cities and urban areas, but at the county level. Additionally, the resource guide should be put into a pamphlet or brochure to ensure access for people with limited or no internet access.

Given our focus on youth, it is critical to discuss the importance of medical decision-making for TGD people under eighteen. Clark and Virani [ 34 ] explored the ethical concerns of providing medical care for TGD youth and found that TGD youth have the individual capacity to make decisions related to their own gender care. Importantly, the age of consent for medical treatment may vary by state and medical intervention, creating a potential barrier for access to affirming care. Even providers skilled in TGD care should expand their knowledge of frameworks such as positive youth development and how it intersects with TGD justice and empowerment [ 34 ].

Finally, there are important implications for research to note. We focused our study on one state in the Midwest; future research should continue to explore understudied geographic areas, including the Midwest, but also rural communities, the Southern U.S., and relevant global contexts. Additionally, future research should consider how to promote active and inclusive participation from participants while also generating findings that are more generalizable to larger groups of TGD youth. Survey methods that compare the experiences of TGD youth across states with varying policy contexts and sociopolitical environments may also be useful. Finally, innovative and less oft used methods, such as multiple case studies, provide researchers with tools to explore healthcare and health experiences with TGD and other marginalized youth in unique and nuanced ways. It may be helpful to use this type of method with states or healthcare systems as the ‘cases’ to better understand TGD youth’s experiences within these different contexts.

5. Conclusions

Numerous studies have shown that TGD youth face multiple barriers to accessing gender-affirming care. This study explored those access-oriented and gender-affirming-care-oriented barriers for white TGD youth in the Midwest who have supportive families. Even with supportive and financially stable families, these families identified barriers to accessing gender-affirming care. These barriers included a lack of access to physicians, accessing gender-affirming care financially and geographically, a lack of information and resources about gender-affirming care, and safety concerns of accessing gender-affirming care. Families identified a lack of affirming care as a barrier to access when attempting to access information on healthcare providers with knowledge about or referrals for gender-affirming care for TGD youth, when seeking information or referrals from healthcare providers, and when required to engage gendered space to access gender-affirming care. These barriers present important implications for practice and further research.

Author Contributions

Conceptualization, M.S.P., T.D.M.; methodology, M.S.P., T.D.M.; formal analysis, M.S.P., T.D.M., D.H., J.A.; writing—original draft preparation, M.S.P., J.A., M.M.C.T., I.S.; writing, T.D.M., D.H.; supervision, M.S.P.; project administration, M.S.P.; funding acquisition, M.S.P. All authors have read and agreed to the published version of the manuscript.

This study was funded by the University of Kansas General Research Fund. The University of Kansas School of Social Welfare Research Office provided funding for the open-access fees.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of The University of Kansas (protocol code 144088 and 6/7/2019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Article Contents

Introduction, materials and methods.

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The choice of gender: is elective gender selection, indeed, sexist?

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Norbert Gleicher, David H. Barad, The choice of gender: is elective gender selection, indeed, sexist?, Human Reproduction , Volume 22, Issue 11, November 2007, Pages 3038–3041, https://doi.org/10.1093/humrep/dem227

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Like a number of international organizations before them, the American College of Obstetricians and Gynecologists (ACOG) recently issued an ethics opinion, which condemned all indications of elective gender selection as devaluatory to women and sexist and, therefore, given the choice, assumed automatic preference for male gender selection in all populations. This study intended to investigate this notion for accuracy.

We investigated the desired gender in 92 couples who had undergone between January 2004 and December 2006 first in vitro fertilization (IVF) cycles in attempts at gender selection for family balancing purposes. Their choices were then also investigated stratified for the ethnicity of the couple.

Among 92 cycles, 36 cycles were selected for female and 56 for male ( P = 0.037). An analysis based on the couples' ethnicities revealed, however, considerable differences in gender selection patterns. Especially Chinese (21 out of 22), Arab/Muslim (5 out of 6) and Asian-Indian (5 out of 5) couples primarily selected for males. Other ethnicities, however, actually preferentially selected for female gender (34 female, 25 male selections in 59 cycles). Gender choices thus varied in a statistically significant way between ethnicities ( P < 0.001).

In an ethnically mixed patient population, elective gender selection for family balancing purposes in most ethnic groups does not represent a discriminatory procedure against female equality. However, cultural biases against females are, indeed, still maintained in some minority populations. Ethics opinions should be considerate of minority opinions, but should be based on prevalent sentiments in a majority of the population.

Elective gender selection has remained controversial worldwide. In the United States (US), the issue had remained largely dormant until the Ethics Committee of the American Society for Reproductive Medicine (ASRM) published an opinion, potentially validating elective gender selection under selected circumstances (Ethics Committee of the American Society for Reproductive Medicine, 2001) . This publication gave rise to controversy in the US ( Gleicher and Karande, 2002 ; Robertson, 2002a ), matching differences of opinion elsewhere in the world ( United Nations, 1995 ; Human Fertilisation and Embryology Authority, 2003 ; FIGO, 2006 ).

Some ethics opinions (from major professional societies) have differentiated between ‘pre-fertilization' gender selection by sperm sorting, and ‘post-fertilization' sex selection through in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD), with the former considered more ethically acceptable than the latter ( Robertson, 2002b ). The reasons are complex, with many ethicists considering the creation of a human embryo as a differentiating step ( ACOG, 2007 ). A recently issued opinion by the Ethics Committee of the American College of Obstetricians and Gynecologists (ACOG), however, placed a surprising degree of emphasis on a different argument: in following the reasoning of the International Federation of Gynecology and Obstetrics ( FIGO, 2006 ), it considers all forms of elective gender selection as discriminatory and sexist ( ACOG, 2007 ).

In its opinion, the ACOG committee states, ‘The committee shares the concerns expressed by the United Nations and the International Federation of Gynecology and Obstetrics that sex selection can be motivated by and reinforce the devaluation of women'. Continuing, the Committee concluded that, ‘…the use of sex selection techniques for family balancing violates the norm of equality between the sexes; moreover, this ethical objection arises regardless of the timing of the selection (i.e. preconception or postconception) or the stage of development of the embryo or fetus' ( ACOG, 2007 ).

Such an implied utilization of elective gender selection for sexist and discriminatory purposes, devaluatory to women, of course implies that, given the opportunity, a large majority of couples would choose gender selection for male offspring. This contention has been disputed on theoretical grounds ( Dahl, 2003 ; Heyd, 2003 ; Dahl et al. , 2006a ), and based on population surveys ( Dahl et al. , 2003 ; Jain et al. , 2005 ; Dahl et al. , 2006b ; Fejes et al. , 2006 ), but still has lead to international regulatory and legal prohibitions ( United Nations, 1995 ; Robertson, 2002b ; Human Fertilization and Embryology Authority, 2003 ; FIGO, 2006 ), although, in an exception, the House of Commons Science and Technology Committee of the United Kingdom recently adopted less dogmatic recommendations ( House of Commons, 2005 ; Pennings, 2005 ; Schulman, 2005 ).

The issue has, however, never before objectively been investigated. This study attempts such an investigation in a multi-ethnic US patient population, which chose to undergo gender selection procedures for family balancing purposes.

Following extensive discussion, involving the Center's Institutional Review Board, and discussed in detail elsewhere ( Gleicher and Karande, 2002 ), our Center has been offering elective gender selection for family balancing purposes by IVF and PGD, in accordance with most recent ASRM guidelines (Ethics Committee of the American Society for Reproductive Medicine, 2004) , since 2004. During that time period, 101 such cycles were performed, of which 92 were first treatment cycles.

Cycles were considered qualified for the study if embryology and informed consent records indicated that (at least) one purpose of PGD was elective gender selection for family balancing purposes. An objective need for family balancing was, in accordance with Robertson, considered to exist when at least one prior child was alive ( Robertson, 2003 ). We, therefore, excluded a single case, where the cycle was performed on a single (Caucasian) female, in her first pregnancy, based on a psychiatric recommendation for female selection.

All patients in this series underwent gender selection by IVF and PGD, though six cycles, concomitantly underwent semen sorting, using the MicroSort sperm separation technique ( Fugger et al. , 1998 ). Nine cycles involved oocyte donations. The patients' clinical, as well as embryology, records were reviewed to determine whether their gender selections were performed for elective conception with female or male embryos. If patients underwent repeat cycles, only their first IVF cycle was considered for analysis.

Records were also reviewed to establish ethnicity of the couple. Patients were assigned, based on the ethnicity of the female, although none of the couples demonstrated divergence in ethnicity between husband and wife. Caucasian and Hispanic patients were analyzed together because a differentiation was not reliably possible. Among 98 couples, 52 were Caucasian/Hispanic, 22 Chinese, 5 Asian-Indian, 5 African/African-American/African-Caribbean, 6 Arab/Muslim and 2 of other Asian ethnicities.

Statistical comparisons between groups were made using SPSS for windows, standard version 10.0.7. Data are, where applicable, presented as mean ± one standard deviation. Group outcomes were compared using Pearson chi-square, chi-square and Fisher's exact test. A level of significance was defined as P < 0.05.

Since this study involved the retroactive review of medical records, and since informed consents, signed by all patients at our Center, allow for the anonymous evaluation of their records for study purposes, no approval from the Center's Institutional Review Board (IRB) was required for this study. The Center's IVF program is under annual IRB review and its gender selection practice has been approved ( Gleicher and Karande, 2002 ).

Among 101 gender selection cycles, 92 were first cycles. Among those, 36 (39.1%) were performed for the selection of female, and 56 (60.9%) for the selection of male embryos ( P = 0.037). Gender selection choices were to a statistically significant degree dependent on the couple's ethnicity ( P < 0.001). Table  1 summarizes gender selections, broken down by ethnic backgrounds. As can be seen, there was obvious gender bias in favor of male selection among Chinese, Arab/Muslim and Asian-Indian couples. In contrast, Caucasian/Hispanic couples demonstrated obvious bias toward female selection. The number of couples from other minorities was too small to reach conclusions.

Gender selections by ethnicity

*Gender selection was to a statistically significant degree ( P < 0.0001) affected by ethnicity.

**Includes African, African-American and African Caribbean.

Mean ages did not differ significantly between ethnicities. They were 36.4 ± 5.4 (range 25–51) years for Caucasian/Hispanics, 36.4 ± 7.1 (range 22–47) for Chinese, 33.4 ± 6.9 (range 25–41) for Asian-Indians, 34.2 ± 1.6 (range 33–37) for women of African descend, 31.5 ± 7.0 (range 22–41) for Arab/Muslims and 39.0 ± 12.7 (range 30–48) years for other Asians. Asian women were, however, overall younger than non-Asian patients (35.3 ± 7.3 years versus 36.2 ± 5.2 years; P = 0.006). Women of younger age with greater statistical likelihood selected for male than female ( P = 0.016).

The results of this study demonstrate overall a statistically larger demand for male than female gender selection. When these data are, however, further analyzed, it becomes apparent that the demand for males is driven by strong biases toward male selection in only some ethnic minorities. Except for Chinese, Arab/Muslim and Asian-Indian patients, no other ethnic group demonstrates a bias toward male selection. Indeed, the opposite is true, especially among Caucasian/Hispanic patients, where 59.6% of selections were for female. This finding confirms previously expressed opinions ( Dahl, 2003 ; Heyd, 2003 ; Dahl et al. , 2006a ), and population surveys in a number of countries ( Dahl et al. , 2003 ; Jain et al. , 2005 ; Dahl et al. , 2006b ; Fejes et al. , 2006 ), which have argued that the introduction of elective gender selection would, at least in the developed world, not affect gender ratios to a significant degree.

In the US, two prior surveys have addressed this issue: Jain et al . noted a significant preference for female gender, especially in older women, who were not religious, had more living children, had only sons and carried a diagnosis of male factor infertility. Interestingly, nulliparous women, who, of course, were not the subject of our study, did not demonstrate preference for the selection of one gender over the other. Among parous women, the distribution of gender among their children significantly affected their preferred choices: those with only daughters preferred to select for male; those with only sons preferred selection for female, thus validating the concept of family balancing ( Jain et al. , 2005 ).

Dahl et al. (2006b) noted that 50% of men and women wished to have a balanced family, 7% wanted more boys, 6% more girls, 5% with only boys, 4% with only girls and 27% had no preference.

Our study did not demonstrate that age represented a contributing factor toward the differences observed between ethnic groups. Asian patients were, however, minimally younger than non-Asian and younger age predisposed to male selection. Especially remarkable was the fact that the two most committed ethnic groups, Caucasian/Hispanic (to female selection) and Chinese (to male selection), were almost identical in mean ages.

This study also contradicts the argument that offering elective gender selection for family balancing purposes ‘always' is discriminatory against females and should, therefore, ‘always' be considered sexist, as expressed by the United Nations ( United Nations, 1995 ), a recent ACOG Ethics Opinion ( ACOG, 2007 ) and in a number of ethical opinions in the literature ( Hanson et al. , 2002 ; Shenfield, 2005 ). The data presented here instead suggest that in the US, the situation is more complex: although certain minorities may still have maintained cultural biases of their homelands, a majority of remaining couples do not demonstrate discriminatory, or sexist, behavior toward females. Indeed, this majority may actually act discriminatorily against males by predominantly selecting for female. Discrimination against male gender has, however, to our best knowledge, never been recognized by any of the international ethical panels, commenting on this issue.

This study does not address the potential choice that gender couples would prefer in first pregnancies. Although the studies by Jain et al. (2005) and Dahl et al. (2006b) suggest that expected findings should not differ significantly from those reported in this study, such a conclusion remains to be confirmed by future studies in the field.

As a New York based fertility center, our program appears well suited to investigate this issue because many of our patients represent ethnic minorities, where, for cultural reasons, gender discrimination in favor of male selection can, indeed, be expected ( Farooqui, 1990 ; Wang, 1990 ; Tuan, 1992 ; Malhi and Singh, 1995 ). The 22 Chinese, 6 Arab/Muslim and 6 Asian-Indian couples, who to a significant degree favored male selection, represent the approximate overall representations of these ethnic groups within our center's patient population. It is, therefore, reassuring that the availability of gender section for family balancing purposes does not appear to have selectively drawn couples from these two minorities.

In the US, ethnic minorities are usually concentrated in large urban centers. For example, Chinese minorities can be found in largest numbers in New York City and San Francisco areas, whereas Arab/Muslim populations concentrate in the New York City and Michigan areas. The ethnic biases presented here toward male gender selection will, therefore, only be visible in relatively small parts of the country.

Other minorities were represented in only small sample sizes, and lack of obvious biases can, therefore, not necessarily be understood as absence of such biases. Further studies, involving larger patient populations, are needed to fully absolve other minority populations from anti-female biases.

At the same time, this study, also suggests that in a less ethnically diverse population, representing a more homogenous Caucasian/Hispanic population, and thus a large majority of the US population, one, indeed, can expect no bias toward male selections and, potentially, even bias toward the selection of females.

This observation suggests that in an ethnically diverse, and economically developed country, like the US, the offer of elective gender selection for family balancing purposes does not necessarily violate the norm of equality between the sexes to the disfavor of females, as suggested in the recent Ethics Opinion of ACOG ( ACOG, 2007 ), and, therefore, does not universally appear to represent a discriminatory and sexist medical practice.

Yet, at the same time these findings raise the question that how obviously existing biases toward male gender selection in certain minority populations should be addressed. We have given considerable thought to this issue but have been unable to reach an unequivocal answer: on the one hand, we strongly believe in the right of patients to choose the make up of their families ( Gleicher and Karande, 2002 ); however, our belief in such rights is, of course, predicated on free choice for each individual, which in an enlightened society will, as most published data, and this study have demonstrated, lead to an approximately equal gender distribution, not discriminatory toward females. When such free choice, based on ethnic habits and/or pressures, is lacking, it would seem only fair to withhold the right to choose the gender make up of one's family. The decision to withhold the right of elective gender selection would, therefore, appear appropriate in countries where widespread discrimination against females, indeed, exists.

Moral and ethical values, however, vary in different societies and, as this study demonstrated, in different ethnicities within US society. It would, therefore, appear mistaken to assume that universal ethics opinion can be developed for worldwide consumption, as suggested by the United Nations' opinion on elective gender selection ( United Nations, 1995 ), and by some individuals ( Shenfield, 2005 ). Instead, developed nations would be well advised to develop educational outreach programs for their ethnic minorities, which teach non-discriminatory value systems, while allowing the conduct of practices, which are not abused by a large majority of the population.

It seems reasonable to assume that in developed countries ethnic biases will fade over time as new generations are influenced by their new homeland's cultural habits. Our experience with elective gender selection also indicates that, independent of ethnicity, the choice to pursue this process is in over 80% of couples initiated by the woman (Gleicher and Barad, Unpublished data). In developed countries, with mixed ethnic populations, like the US, this observation suggests that a psychological investigation, prior to initiation of treatment, may allow for an objective differentiation between women who chose gender selection out of free will, and those who feel coerced. Such a psychological examination could then, in a non-discriminatory way, be used to determine who should, and who should not, be given access to selective gender determination of their offspring.

We in that sense agree with Dahl who commented that outlawing a harmless practice in one country, simply because it has been demonstrated to have potentially harmful effects elsewhere in the world, represents bad public policy ( Dahl, 2005 ). Similarly, there is no reason to impose ethics opinions on a whole nation, simply because a small minority acts in an unethical fashion. Ethical advisories should, in their respective opinions, be more considerate of national value systems, and should not attempt to find consensus, based on lowest common denominators.

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Bioethics, Sex Selection, and Gender Equity

• First Online: 02 July 2022

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• Laura Rahm 4 , 5  

Part of the book series: International Handbooks of Population ((IHOP,volume 11))

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Recent decades have seen major advances in assisted reproductive technology, allowing couples to have more autonomy over their reproductive goals. However, new technologies have also caused disturbing trends in sex selection that have threatened the gender balance in large countries like China and India. This chapter examines the emerging challenges and ethical dimensions of technological developments in reproduction as well as their policy implications. Drawing from latest population data, the chapter highlights the impact of selective reproductive technology on demographic trends (in particular, on sex ratios at birth). It also assesses the influence and surprising backlashes of public policies that have been put in place to limit the negative aspects of these new technologies. The chapter is illustrated with country examples. Bioethics and gender have long focused on individual rights, but the larger demographic consequences of reproductive technologies are invisible at this level. The chapter calls on demographers to enrich the bioethical debate through a population lens on bioethics.

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Introduction: Kinds of Children

Reproductive Autonomy: Sex Selection as a Defining Case Study

Sex Selection for Daughters: Demographic Consequences of Female-Biased Sex Ratios

Deselection of daughters refers to prenatal fetal sex diagnosis followed by selective abortions of female fetuses.

Medical abortion consists of taking two different abortion pills (using a combination of mifepristone and misoprostol) to end the pregnancy. It is usually available up to 10 weeks of gestation. Meanwhile, surgical abortions involve an operation to remove the pregnancy from the womb. Common methods using local or general anesthetic are aspiration up to 14 weeks of gestation or dilation and evacuation for second trimester abortions (see Chap. 28 : The Role of Abortion in Population Policies of this Handbook [Crane & Maistrellis, this volume ]).

According to Reuters, the business of sex selection is estimated to be worth USD 150 million in 2013, with a growing demand of about 20% per year (Kaye & Jittapong, 2014 ).

For example, one 1997 poster campaign read, “I want to be born with the blessing of mama and papa. I am frightened of abortion for being a girl. Please protect my life” (Rahm, 2020 : 118).

See Chap. 24 : Measuring the Effectiveness, Efficiency, and Impact of Population Policies of this Handbook (Tarsilla, this volume ).

By political masculinities, we refer to both individual and institutionalized expressions of masculinity; see Rahm, 2019 .

Peters and Nagel ( 2020 : 1) in their new book coin these failed persisting policy ideas as “zombie ideas”.

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Rahm, L. (2022). Bioethics, Sex Selection, and Gender Equity. In: May, J.F., Goldstone, J.A. (eds) International Handbook of Population Policies. International Handbooks of Population, vol 11. Springer, Cham. https://doi.org/10.1007/978-3-031-02040-7_33

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• Published: 15 November 2022

The history of sexual selection research provides insights as to why females are still understudied

• Malin Ah-King   ORCID: orcid.org/0000-0001-7108-2275 1  

Nature Communications volume  13 , Article number:  6976 ( 2022 ) Cite this article

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• Interdisciplinary studies
• Sexual selection

While it is widely acknowledged that Darwin’s descriptions of females were gender-biased, gender bias in current sexual selection research is less recognized. An examination of the history of sexual selection research shows prevalent male precedence—that research starts with male-centered investigations or explanations and thereafter includes female-centered equivalents. In comparison, the incidence of female precedence is low. Furthermore, a comparison between the volume of publications focusing on sexual selection in males versus in females shows that the former far outnumber the latter. This bias is not only a historical pattern; sexual selection theory and research are still male-centered—due to conspicuous traits, practical obstacles, and continued gender bias. Even the way sexual selection is commonly defined contributes to this bias. This history provides an illustrative example by which we can learn to recognize biases and identify gaps in knowledge. I conclude with a call for the scientific community to interrogate its own biases and suggest strategies for alleviating biases in this field and beyond.

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Introduction.

Scientific methodology aims at objectivity, that is for the results of science not to be influenced by subjective factors such as values or personal interests. Yet, history shows that such influences have distorted scientific knowledge; for example, medical science considered female bodies as deviant from a male norm 1 . That is so because scientists are people in a specific time and place whose thinking reflects ‘truths’ as currently accepted by the wider society 2 . Such biases have influenced the questions asked, hypotheses formulated, and interpretations drawn from data—how and why knowledge has been produced 1 . Furthermore, they also impact what we do not know 3 . The history of sexual selection research provides an illustrative example of knowledge/ignorance production by which we can learn to counteract biases.

It is now more than 150 years since Charles Darwin published The Descent of Man and Selection in Relation to Sex 4 , and sexual selection has been through an odyssey of disbelief, slumbering existence and blooming, and numerous controversies. In Darwin and the making of Sexual Selection 5 , science historian Evelleen Richards convincingly demonstrates how sexual selection history is imbued by its gendered social context. Thus, controversies around females are salient—early on about women’s intelligence, whether female animals have mental capacities for mate choice, and later on about female agency in mating 5 and fertilization 6 . Darwin’s contemporary colleagues rejected female choice as a mechanism of sexual selection, because they did not think that animals could have the aesthetic sensibility for choice, nor that females were active in sexual encounters 5 , 7 . When the study of sexual selection was revived in the 1970s, Darwin’s Victorian assumptions about coy and passive females lingered 8 , 9 . Now, over 50 years later, through a still ongoing process of controversies and negotiations of scientific knowledge, evolutionary biologists have bit by bit moved away from perceptions of females as coy and passive, towards acknowledging that females can have active sexual strategies, be fiercely aggressive, dominant and variable among themselves 6 , 9 . This history is highly intriguing as it concerns the development of scientific knowledge as well as biases in science; furthermore, it is important for the future of the field. By analyzing this history, we can learn to recognize biases, identify gaps in knowledge and better understand how to counteract such biases in future work.

I use epistemology of ignorance (agnotology)—the examination of how knowledge has been ignored, delayed or not formed 3 , 10 , 11 —to explore how knowledge about females has been delayed, or not produced, in sexual selection research. Here, I investigate whether research in sexual selection tends to begin as male-centered and thereafter shift to include female-centered equivalents (a pattern I call male precedence) or vice versa (female precedence). I also investigate how the frequency of publications focusing on sexual selection in males versus in females has changed over time. Thereafter, I discuss the potential causes and consequences of these patterns. Finally, I conclude with suggestions for alleviating biases in this field and beyond, a call for the scientific community to interrogate its own biases and perspectives—in basic assumptions, choice of research questions, study species, methodologies, and interpretations of results, in research priorities by funding agencies, as well as in journals’ assessments in the publication process.

Areas of male precedence

I searched the literature on the history of sexual selection research, scientific reviews, and papers on the state-of-the-art in and critique of sexual selection to identify male versus female precedence. Even though sexual selection is the outcome of interactions between males and females, I characterize investigations as male-centered (if they focus on the variation in reproductive success among males and thus trait evolution in males) and female-centered (if conversely, they focus on variation in reproductive success among females and trait evolution in females) in order to identify male and female precedence. In my review, the most common pattern was male precedence, whereas female precedence was scarce. Here I illustrate prominent areas of male precedence, followed by contrasting areas of female precedence in the next section.

Male ornamentation and trait evolution

Most studies of sexual selection have focused on trait evolution in males through variation in male reproductive success, rather than equivalent questions for females. In Malte Andersson’s book Sexual Selection from 1994, he provides a review of empirical studies conducted until 1990 12 . Most of those studies (167) concern how male traits evolve through female choice. The majority of these studies investigated sexual selection on male song or display, followed by size and visual ornaments. In contrast, studies on how female traits evolve through male choice comprised thirty studies, mostly on sexual selection for large female size. Of the male-centered studies, the earliest was published in 1944, followed by some studies from the 1960s and an increasing number from the 1970s, whereas the earliest female-centered study was published in 1955, with more studies emerging in the 1970s.

In Andersson’s review 12 , another large segment of studies focused on intrasexual contests, which contribute to sexual selection by influencing variance in mating success. Studies of male contests and related traits such as horns, antlers, tusks, and spurs (58) outnumber, and many also precede, the two studies of female contests (from 1983 and 1988). In addition, the same pattern of male precedence applies to the more specific areas of studies in nuptial coloration in sticklebacks 13 and birdsong 14 .

Genital evolution

William Eberhard’s book on Sexual selection and animal genitalia (1985) showed that male copulatory organs have been overwhelmingly overrepresented in the study of animal genitalia and introduced the sexual selection framework for studying them 15 . Studying female genitalia has lagged behind, and a review of genital evolution publications in 2014 showed that the field was still male-biased 16 . One recent example of male precedence in genital evolution research is the study of male spermatophores versus the female corpus bursa in butterflies. Butterfly spermatophores and their functions had been studied for many years 12 before researchers started to investigate the female genital structure that receives spermatophores—the corpus bursa —and the function of the toothlike structures inside it, signa . Finally, research now investigates the operation of signa 17 , the sexually antagonistic coevolution between signa and spermatophore envelopes 18 , as well as the enzyme activity of the corpus bursa 19 .

Interpretations of female multiple mating in birds—male infliction or active female choice?

Females were long expected to mate with only one male, especially among socially monogamous birds. With DNA technology, researchers discovered widespread female multiple mating among birds. Behavioral studies of extra-pair copulations indicated that in the majority of species, these were forced 20 . Accordingly, researchers initially interpreted this extra-pair mating as due to males forcing or harassing females to mate multiply 20 , 21 , or alternatively, that territorial males failed to defend their mates against other males 22 . Thus, early research interpreted extra-pair mating as a male strategy 23 , 24 , 25 , 26 . Despite these prevailing interpretations of females as passive, there exist very early accounts of females initiating or readily accepting to mate with other males than their social mate 27 , but these interpretations were ignored or re-interpreted as (possibly) “apparent willingness” rather than “real” 20 . Thus, the prevailing view until the mid-1990s was that male strategies caused extra-pair mating patterns 25 . However, in contrast to prevailing assumptions of passive females, in 1988, ornithologist Susan Smith demonstrated that black-capped chickadee females actively seek out higher-ranked males in their territories to initiate mating 22 . Since then, there has been a slow shift towards acknowledging female multiple mating as an active female strategy, at least in some species 6 .

Sperm competition versus cryptic female choice

Darwin’s sexual selection theory concerned competition that occurred before mating. In 1970, Geoff Parker’s theory of sperm competition extended sexual selection theory to events occurring after copulation, with its male-centered focus on competition between sperm from different males for the fertilization of a set of eggs 28 . The equivalent female-centered theory, cryptic female choice (the female influencing which sperm fertilize her eggs) was developed by Randy Thornhill and colleagues some years later 29 , 30 , 31 . The sperm competition field developed before that of cryptic female choice, and is still many times more productive in terms of published papers (Fig.  1 ).

Comparison of number of publications on sexual selection (blue line), sperm competition (orange line), and cryptic female choice (gray line) over time. Sperm competition studies by far outnumber cryptic female choice studies. The total number of papers published on sperm competition is 5219 compared to 728 on cryptic female choice, and the ratio for year 2021 is 147 versus 29. The number of publications were retrieved from Web of Science searches in “all fields” for “sexual selection”, “sperm competition” and “cryptic female choice” (June 6, 2022).

Infanticide

Primatologist Sarah Blaffer Hrdy was the first to suggest that infanticide by males of unrelated infants could be a sexually selected strategy in 1974 32 . She reasoned that if a male killed a female’s unweaned infant, the female could conceive his offspring quicker and thereby increase his reproductive success. Although both males and females may commit infanticide of unrelated infants, among the multiple hypotheses suggested, it is only when males are perpetrators that the sexual selection hypothesis is suggested as an explanation, because males potentially increase their reproductive success by reducing female remating latency 33 . For females, on the other hand, committing infanticide produces no equivalent effect, but may increase their reproductive success through, for example, resource competition, which is then explained by natural selection. Therefore, sexual selection research includes a multitude of studies on males committing infanticide 34 . Reviewing the sexual selection and infanticide literature (Web of Science search of “all fields” for “infanticide and ‘sexual selection’” May 27, 2022), the majority of studies (109 of 122) describe sexually selected infanticide as a strategy restricted to males. However, since 1991, some studies (13), especially on birds, describe it as a sexually selected strategy in both sexes (both sexes may increase their fitness by killing unrelated offspring, however, females compete for opportunities to reproduce rather than to mate), and the subject of sexually selected infanticide by female animals has gained more attention 35 , 36 , 37 . Thus, there is male precedence in the literature on sexually selected infanticide, but as several authors have pointed out, whether or not infanticide by females is considered sexual selection depends on how sexual selection is defined, which I discuss further below.

Sexual conflict

Although many issues in sexual selection involve conflict between the sexes (sexual conflict), such as infanticide, the sexual conflict field only emerged in the 1990s and has focused particularly on male reproductive traits that impose a cost on female fitness during or after copulation 38 , 39 . In their 2011 investigation of the field, Kristina Karlsson Green and Josefin Madjidian point out that theoretical models of sexual conflict primarily focus on traits which incur benefits to males and costs for females 40 . Moreover, Melissa Plakke and colleagues assert that equivalent research on females has lagged behind, but that in all systems where females have been meticulously studied, female reproductive adaptations of sexual conflict have been identified 19 . Thus, there was male precedence in the sexual conflict field.

Furthermore, Marlene Zuk and colleagues assert that early studies of sexual conflict were biased towards a few insect model species which exhibit more or less intense sexual conflict, and in which sexual conflict is costly to females. As the model systems in sexual conflict studies diversified over time, the support for the view that sexual conflict always results in harm of females decreased 41 . Thus, the choice of model species influences the conclusions drawn.

Areas of female precedence

While there are more areas with male precedence, a few areas show female precedence. Models about the evolution of mate preferences have primarily focused on female preferences 12 . For example, the idea that female sensory biases (preferences that have evolved in a non-mating context and which are not necessarily sex-specific) make them prefer certain male traits in mate choice, preceded the suggestion that males may also have sensory biases for female traits 42 , 43 .

Another possible example of female precedence is maternal and paternal effects, that is when a parent affects the phenotype of offspring through other means than genetic inheritance. A review on maternal and paternal effects and sexual selection gives examples of females that mate with attractive partners providing more resources to the offspring (maternal effect studies from 1986, 1998, 2000) 44 . However, among their empirical examples of parental effects on sexually selected traits, there is no clear pattern of female precedence.

Yet another potential example of female precedence is priming, that a hormonal stimulus may influence reproductive condition and behavior. For example in rodents, male odor can induce maturation and ovulation in females (which might be a sexually selected adaptation) 45 .

Quantifying studies on sexual selection in males versus females

I compared the volume of publications focusing on sexual selection in males versus those focusing on sexual selection in females. Specifically, I compared the numbers of studies on variance in male reproductive success (identified by the search terms “female choice” and “male competition”) to those on variance in female reproductive success (“male choice” and “female competition”). Although this is a rough measure, it shows that studies in the field are more frequently focusing on sexual selection in males than on sexual selection in females (Fig.  2 ), which suggests that sexual selection in females is understudied. Studies of both male choice and female competition are few throughout the period, and very few in comparison to studies on female choice and male competition.

Number of publications on female choice (green dashed line) and male competition (green dotted line), both mechanisms concern variance in male reproductive success, and added together gives the number of publications on sexual selection in males (green solid line)—compared with publications on male choice (blue dashed line) and female competition (blue dotted line), mechanisms which concern the variance in female reproductive success, which added together gives the number of publications on selection in females (blue solid line). The figure shows that studies investigating sexual selection in males outnumber studies of sexual selection in females. Data from Web of Science (June 6, 2022).

Causes and consequences of bias

Although it may be difficult to attribute a biased research pattern to a specific kind of researcher bias, it is important to recognize that there are different kinds of biases. Secondary sexual characteristics are usually more developed in males, especially the extravagant plumages in birds. Such extraordinary ornaments posed a challenge to Darwin’s theory of evolution by natural selection as they should decrease survival, and thus it is not surprising that bird ornaments and song were central to Darwin’s ideas about sexual selection 5 . Similarly, it seems reasonable that contemporary research started out with the more visible male characteristics and that studies of the less conspicuous equivalent female traits followed later, though in a few species these traits are even more pronounced in females than in males 46 . Furthermore, in some cases there may be practical reasons that females are understudied. For example, it can be more difficult to study internal, often soft tissue female genitalia and the process of gamete selection within the female body (or methods for doing so have not been established yet), compared to studying external male genitalia and testing some predictions of sperm competition (e.g., counting sperm and weighing testicles).

Yet, not all the bias can be explained by the biological features of the study systems. Presumptions about sexual selection being weaker or non-existent in females, as well as assumptions of females as “coy” and passive, have led to an over-emphasis on sexual selection in males and disregard of evolution in females 2 , 8 , 9 . For example, there is no logical reason that the female-focused idea (cryptic female choice) should emerge later than the male-focused one (sperm competition) when sexual selection theory was expanded to include events after mating. This may instead reflect gender bias by androcentrism (male centeredness, which is primarily focusing on features associated with males and failing to study features associated with females 47 .

Still another cause of bias is the currently prevailing definition of sexual selection, which excludes many ways in which females compete for reproduction.

A bias due to the definition of sexual selection itself

Darwin provided two definitions of sexual selection: in Origin of Species (1859) 48 , his first definition was “Sexual selection… depends, not on a struggle for existence, but on a struggle between the males for possession of the females; the result is not death to the unsuccessful competitor, but few or no offspring” 48 . This is a narrow sense definition 49 , since it is restricted to sexual selection in males and only includes competition for mates. Later, in the Descent of Man and Selection in Relation to Sex , Darwin wrote “Sexual selection … depends on the advantage which certain individuals have over other individuals of the same sex and species, in exclusive relation to reproduction” 4 . This broad-sense definition is more inclusive because it encompasses sexual selection in both sexes as well as competition beyond the struggle for mates. Even more than 150 years later, there is an ongoing debate about how to define sexual selection 50 . In practice, the currently most prevailing definition of sexual selection is “differences in reproduction that arise from variation among individuals in traits that affect success in competition over mates and fertilizations” 12 , 51 , 52 . Though this includes both females and males, it is a narrow-sense definition because it excludes many ways in which females compete among each other for reproduction—such as competition for opportunities to breed or rear young 53 , nest parasitism (laying eggs in other females’ nests), female–female aggression (for resources other than mates) 49 , 54 , female competition for offspring care 55 and infanticide by females 35 . How to solve this problem is up to the research community, but is important to be aware that the prevailing terminology largely excludes female competition for reproduction and thereby produces ignorance about broad-sense sexual selection in females (Fig.  3 ).

Illustration of which selection mechanisms are included in the currently prevailing definition of sexual selection compared to Darwin’s broad sense sexual selection and West Eberhard’s social selection.

Consequences of bias

Male precedence is a kind of androcentrism. Although the prevalent male precedence in sexual selection research can partly be attributed to biological patterns, partly it is also due to cultural gender bias. The history of sexual selection research shows that overfocusing on males has obscured the role of females as well as the evolution of females 56 . Ignorance has been produced through delays or hindrances of knowledge production about female evolution 2 , 9 , 19 , and disregard of existing research or alternative interpretations 6 , 9 (Fig.  4 ). One example of such gender bias was demonstrated in Marcy Lawton and colleagues’ analysis of ornithological research 57 . In a book on pinyon jays, the authors dismissed female aggression as the bird version of PMS, rather than recognizing that females hold territories and rule dominance hierarchies in this particular species.

Although the higher frequency of extraordinary male ornaments in males may partly explain the prevalent male precedence (that is research starts with focusing on male-centered investigations or explanations and thereafter include female-centered equivalents), it is also partly due to gender bias. Such gender bias has delayed or hindered parallel work on females as well as led to disregard of existing research and alternative theoretical interpretations.

Shifting away from androcentric assumptions in the field has repeatedly expanded our understanding of sexual selection—about female ornamentation 13 , female birdsong 14 , the role of females in extra-pair copulations 58 , and fertilization 59 . Likewise, shifting from stereotypical assumptions about males has led to new insights in male choice and sperm allocation 58 . Challenging of androcentric assumptions about passive females led to the recognition that females have active sexual strategies, informed new theory 60 , 61 , 62 , and resulted in a more comprehensive understanding of sexual selection 47 , 58 , 63 . However, the prevailing definition of sexual selection still encourages researchers who attend to females to only look for sexual selection as parallel to or similar to that identified in males.

Suggested solutions for the inclusion of female competition

One proposed solution has been to use Darwin’s broad-sense definition 46 , whereby female competition would be categorized as sexual selection, corresponding with male competition. However, Darwin’s broad-sense definition, in particular, brings other problems with distinguishing between sexual and natural selection 50 . Furthermore, a review on female ornamental traits by Joseph Tobias and colleagues shows that within the same species, the same trait often has different functions for females and males 64 . For example, reindeer antlers are sexually selected in males, whereas females use them in competition for access to foraging sites. Furthermore, for both female and male ornaments there is a continuum of functions between sexual selection and non-sexual social competition, although ecological competition is more common in females than in males 64 . Sexual selection is often assumed to be the cause of female ornamentation even though it may have other anti-predator or ecological competition functions. Likewise, sexual selection as an explanation for male ornaments may be overestimated, because males also compete socially for other resources than mates and fertilizations. Thus, using Darwin’s broad sense definition does not resolve the problem that similar traits can be the result of different forms of selection 64 .

A suggested alternative solution is to use Mary Jane West Eberhard’s theoretical framework of social selection (a sub-type of natural selection, including the sub-type sexual selection)—defined as “differential reproductive success (ultimately, differential gene replication) due to differential success in social competition, whatever the resource at stake” 65 . This theoretical framework includes the many different ways in which social competition and cooperation occurs in females and males 49 , 64 , 66 (Fig.  3 ). The narrow sense definition of sexual selection has shortcomings for both sexes, but it works better for males, whereas the framework of social selection is particularly relevant for females 64 . Social selection is a layer of selection that is so far underappreciated 49 , 64 , 66 .

Suggestions for alleviating biases in sexual selection and beyond

Here, I provide suggestions for alleviating biases (see also Box  1 ). As scientists, we all have our own biases—our theoretical frameworks 9 , 16 , 57 , our human senses (which enable certain insights into animal behavior but hinder others 67 , study species 16 , 41 , geographical locations 14 , cultures 68 , and experiences 8 , 14 . Accordingly, science historians and philosophers have shown that the exclusion of certain people based on sex and race has influenced the science produced 69 . Recently, Casey Haines and colleagues showed a connection between an increase in women authors investigating female birdsong and a paradigm shift in this area—from assuming birdsong to be a sexually selected male trait to concluding that female birdsong is widespread and that singing by both sexes is ancestral in birds 70 . The same pattern was noted in the history of primatology, in which a number of pioneering women primatologists with feminist perspectives started to study females in their own right—thereby developing new research questions, challenging language use, and producing new theoretical understandings—leading to a general shift in the field 63 , 71 . In addition, Japanese primatologists interested in a holistic understanding of primate societies, early on recognized female dominance hierarchies that Western primatologists overlooked 68 . In line with these developments, science philosopher Helen Longino argues that research constructed by an adequately diverse community with an open critical dialog and serious consideration of all relevant perspectives are important for enabling progress in scientific knowledge 72 .

Which fractions of nature become known and which remain unknown is the result of negotiations in society and the scientific community 1 . The inclusion of critical analyses of gender bias can improve science 1 , 57 , 72 , 73 , and healthy working relationships between those performing gender analyses of science and those doing science can speed integration of critical analysis of gender bias in science 1 . There is always a multiplicity of theories in a scientific community, and ideological influence, such as androcentric bias, is probably strongest when it leads to the ignorance of certain theoretical interpretations 73 . Therefore, one way of developing science is to explore marginal theories that have been left out because they are perceived as being outside the prevailing paradigm 73 . One way to boost new research is to gather expertize on understudied perspectives in a specific area, as was recently done in a workshop on female reproductive biology 74 , 75 .

When designing experiments, these reflective questions can be useful: Are the assumptions, theoretical background presentation, terminology, and interpretations liable to gender stereotypical bias? 76 Are gender stereotypes perpetuated by ascribing emotional states to behavior (e.g., aggressive, rapacious, voracious)? In sexual selection experiments, is sexual/social selection in both females and males taken into account?

Being aware of biases enables constructing experimental controls 77 , therefore it might be useful to ask colleagues that are least likely to conform to the investigator’s way of thinking to review the experimental design. It may not be possible to test all alternatives in practice, but it is important to always be aware of the broader theoretical possibilities, and consider if the experiment can rule out potential alternative explanations.

When choosing which species to work with, consider what Zuk and colleagues showed, namely that conclusions drawn are influenced by the model system used 41 . Diversifying model systems gives broader perspectives on research questions. Moreover, useful methods for eliminating observer bias are (when possible) “blind” observations, done by investigators who are not aware of the hypothesis being tested, and analyzing subsets of data independently to ensure inter-observer reliability of coding behavior 78 . Furthermore, publishing null results and making replication studies is important to counteract publication bias 79 .

Changing scientific priorities are enabled by funding opportunities, institutional arrangements, and by the scientific community—therefore funding agencies, institutions, journals, editors and reviewers all influence which proportions of nature become known and which are neglected 1 .

Box 1 General strategies for counteracting bias in sexual selection research and beyond

It is important to acknowledge biases and the role of diversity in the scientific community for contributing to previously understudied issues in science. Here follows a list of suggestions to counteract bias at different stages in the research process. Importantly, funding agencies, institutions, journals, editors, and reviewers all influence the research community’s priorities of which proportions of nature to become known and which become neglected 1 .

In planning research: be wary of stereotypical assumptions and that definitions are important for the inclusion/exclusion of issues in an area; recognize that the study subjects enable certain investigations and preclude others; consider alternative theoretical models and hypotheses.

In conducting research: consider potential biases to design experimental controls; use “blind” observations (done by investigators who are not aware of the expected experimental outcome) when possible, and independent analyses of coding behavior to ensure inter-observer reliability.

Interpreting results: be aware that language use and terminology shape interpretations, for example, ascribing emotional states to behavior (e.g., aggressive, rapacious, voracious) can perpetuate stereotypes and lead to confirmation biases. Gender-neutral language and specific operational terminology are useful for reducing gender bias.

For research evaluators and publishers: be wary of unconscious bias; recognize the value of open critical dialog and serious consideration of all relevant perspectives; counteract publication bias by publishing null results and replication studies.

The history of sexual selection research shows prevalent male precedence which has, in particular, delayed knowledge not only about sexual selection in females, but also more broadly about reproduction and evolution in both females and males. This prevalent male precedence can partly be explained by the biological features that are more obvious and more amenable to study, but is also partly due to cultural gender bias. History also shows repeatedly that abandoning stereotypic assumptions about passive females has led to progress in the field.

The quantification of publications in sexual selection shows that studies have historically and continue to focus much more on sexual selection in males than in females. This result in part reflects that sexual selection is often stronger in males, but also that a lot of what females do in terms of competition for reproduction is not included in the prevailing narrow-sense definition of sexual selection—such as female-female reproductive competition for resources other than mates, breeding opportunities to conceive or rear young and laying eggs in other females’ nests. The focus on narrow-sense sexual selection has perpetuated ignorance production about the selection on females. Thus, sexual selection research is still heavily focused on sexual selection in males while sexual selection in females is understudied. Awareness of this bias and increased efforts to counteract it would result in a more comprehensive understanding of evolution. The history of sexual selection illuminates how we can learn to recognize biases and identify knowledge gaps, suggesting strategies for alleviating biases in this field and beyond (Box  1 ).

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Acknowledgements

This project was funded by the Swedish Research Council under Grant number 2016-02048, a travel scholarship from Helge Ax:son Johnson Stiftelse and a one week research stay at Drakamöllan, Sweden. I thank Ingrid Ahnesjö, J.P. Drury, Patricia Gowaty, Marie Herberstein, Mikael Mildén, Sören Nylin, Karen Warkentin, and Cecilia Åse for constructive comments on the manuscript.

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Ah-King, M. The history of sexual selection research provides insights as to why females are still understudied. Nat Commun 13 , 6976 (2022). https://doi.org/10.1038/s41467-022-34770-z

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Received : 03 March 2021

Accepted : 07 November 2022

Published : 15 November 2022

DOI : https://doi.org/10.1038/s41467-022-34770-z

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